Gallbladder carcinoma: evaluation with MR imaging

Differentiating benign from malignant gallbladder wall thickening in non-contrast MRI imaging: Preliminary study of a combined diagnostic indicator

To synthetically evaluate the diagnostic accuracy of image features for differentiating benign from malignant gallbladder wall thickening disease with non-contrast MRI and establish the optimal diagnostic indicator. A total of 23 patients with wall thickening type gallbladder carcinoma and 61 patients with benign wall thickening disease were included. The diagnostic performance of six image features including the layered pattern on T2-weighted imaging (T2WI) and diffusion-weighted imaging (DWI) images, T2WI signal intensity, papillary growth, the apparent diffusion coefficient (ADC) value, and the lesion to liver parenchyma ratio (LLR) of gallbladder were evaluated and compared. The receiver operating characteristic (ROC) curve and binary logistic regression analysis were used to construct the optimally combined indicator. All six indicators showed high diagnostic accuracy. The layered pattern on DWI and LLR had the highest area under the curve (AUC) value (0.904), followed by the layered pattern on T2WI (0.883), T2WI signal intensity (0.859), ADC value (0.836), and papillary growth (0.796). There was no statistically significant difference in the AUC among indicators for pairwise comparisons. A combination of layered patterns on DWI and papillary growth was shown to be the optimal indicator by binary logistic regression analysis. The AUC value of the combination (0.972) was higher than the layered pattern on DWI (0.904) and papillary growth (0.796) (P < .001). Non-contrast MRI provides several reliable indicators for differentiating benign from malignant gallbladder thickening disease. The combination of layered patterns on DWI and papillary growth is the optimal indicator.

Cross-sectional Imaging of Gallbladder Carcinoma: An Update

Gallbladder Carcinoma (GBCA) is the most common biliary tract malignancy. As the disease is often diagnosed clinically in an advanced stage, the survival rates are dismal. Imaging studies allow for an early diagnosis of malignancy, though the findings may be indistinguishable from non-malignant disease processes affecting the gallbladder. Attempts have been made to make a specific diagnosis of GBCA at an early stage on imaging studies. Ultrasonography (US) is the most commonly employed technique for gallbladder evaluation. Gallbladder wall thickening is the most common finding of early GBCA and in this context, US is non-specific. Recently, contrast enhanced ultrasound has been shown to be effective in differentiating benign from malignant disease. Multidetector computed tomography represents the most robust imaging technique in evaluation of GBCA. It provides relatively sensitive evaluation of mural thickening, though it is not entirely specific and issues in differentiating GBCA from xanthogranulomatous cholecystitis do arise. Due to its superior soft tissue resolution, Magnetic Resonance Imaging (MRI) provides excellent delineation of gallbladder and biliary tree involvement. When coupled with functional MRI techniques, such as diffusion-weighted and perfusion imaging, it provides a useful problem solving tool for interrogating the malignant potential of nonspecific gallbladder lesions and detection of metastases. Positron emission tomography has a role in detection of distant metastases and following patients following treatment for malignancy. We review the current role of various imaging modalities in evaluating patients with GBCA.

Ultrasonographic Angiography in Gallbladder Diseases

Ultrasonographic (US) angiography was performed by sonographic examination with injection of carbon dioxide microbubbles through a catheter following conventional angiography in 41 patients with various gallbladder diseases. Three enhancement patterns were found; strong enhancement in the lesion from the periphery to the center was noted in patients with adenocarcinoma and benign polyp (type I), irregular partial enhancement at the margins of the lesion in those with adenosquamous carcinoma (type II), and internal regular enhancement in those with chronic cholecystitis, xanthogranulomatous cholecystitis and adenomyomatosis (type III). Pseudopolypoid lesion such as gallbladder debris showed no enhancement. US angiography may be useful in the differential diagnosis of gallbladder diseases, especially to differentiate the wall thickening type of gallbladder carcinoma from chronic cholecystitis or adenomyomatosis, and the pseudopolypoid lesion and fundal type of adenomyomatosis from benign polyp or polypoid-type carcinoma.

Magnetic resonance differentiation between T2 and T1 gallbladder carcinoma: significance of subserosal enhancement on the delayed phase dynamic study

PURPOSE

The aim of this study is to investigate whether subserosal enhancement on the delayed-phase dynamic magnetic resonance (MR) study (SED) can differentiate T2 from T1 gallbladder carcinoma (GBC).

METHODS

The institutional research board approved this retrospective study. Between 1997 and 2006, there were surgically proven 11 T1 and 21 T2 GBC in 30 patients, all of whom had undergone preoperative contrast enhanced dynamic MR study, either with a 2D sequence (n=17) or 3D sequences (n=15). All images were reviewed by two radiologists for the presence of SED, and receiver operating characteristic (ROC) curve analysis was performed. Sensitivity, specificity, positive and negative predictive values were calculated by consensus.

RESULTS

The areas under the ROC curves of the two readers were 0.91 and 0.86, and the kappa value was 0.78. Of the 21 T2 GBC, 18 and 3 showed positive and negative SED, respectively. Of the 11 T1 GBC, 1 and 10 showed positive and negative SED, respectively. The sensitivity, specificity, positive and negative predictive values of SED for diagnosing T2 lesions were 86%, 88%, 91% and 77%, respectively.

CONCLUSIONS

In conclusion, SED may be a useful sign to differentiate T2 from T1 GBC, which would affect the preoperative surgical planning of the patients.

Magnetic resonance imaging of gallbladder and biliary system

Gallbladder and biliary system pathologic component is a spectrum of benign and malignant conditions. Standard magnetic resonance imaging techniques when used together with magnetic resonance cholangiopancreatography (MRCP) can evaluate gallbladder and biliary system pathologic conditions. Inflammatory diseases are characterized by thickening and intense mucosal contrast enhancement of the affected bile ducts and or gallbladder wall. Postinflammatory changes can be appreciated on MRCP with short or long segment strictures of the bile ducts. Serial contrast-enhanced images show reactive inflammatory changes in the liver parenchyma. Neoplastic diseases of the gallbladder and the biliary tree are evaluated on T2-weighted fat-suppressed echo train and serial contrast-enhanced images and their obstructive effect can be displayed on MRCP images. In this paper, we will review the spectrum of MRI findings of gallbladder and biliary system pathologic conditions.

Application of modern imaging methods in diagnosis of gallbladder cancer

The poor prognosis of gallbladder cancer (GBC) is related to its dissemination capacity and usually late diagnosis due to its non-specific clinical appearance. Recent improvements in hepatobiliary surgery have underlined the importance of an early specific diagnosis, which requires a multidisciplinary approach and, when possible, specialized equipment. The first step in an early diagnosis is to identify patients in the appropriate epidemiological setting (e.g., incidental finding, chronic cholecystitis) for the correct interpretation of test results. It is desirable to enhance the sensitivity of the initial ultrasound (US) examination by use of the appropriate technology in skilled specialist hands. When GBC is suggested by US findings, FDG-PET can be considered complementary to establish the benign/malignant nature of the lesion and to obtain a primary staging study. If GBC is confirmed, thin slice spiral CT can contribute valuable information on local spread. In this regard, recent hybrid PET-CT systems provide structural and functional information simultaneously and may offer early and accurate T, N, and M staging with an improved specificity.

Evaluation of gall bladder carcinoma with dynamic magnetic resonance imaging and magnetic resonance cholangiopancreatography

The objective of this study is to evaluate the efficacy of dynamic MRI with magnetic resonance cholangiopancreatography (MRCP) in the preoperative assessment of gall bladder carcinoma. Magnetic resonance imaging and MRCP were carried out in 15 patients with gall bladder carcinoma before surgery and the imaging findings correlated with surgical and pathological findings. Gall bladder carcinoma manifested as focal or diffuse wall thickening in 73% (11/15) and as a mass replacing the gall bladder in 27% (4/15). All tumours showed enhancement in the early phase, which persisted into the delayed phase. The sensitivity and specificity of MRI with MRCP in detecting hepatic invasion, lymph node metastasis and bile duct invasion was 87.5 and 86%, 60 and 90%, and 80 and 100%, respectively. Magnetic resonance imaging correctly diagnosed duodenal invasion in only 50% and in none of the two patients with peritoneal metastasis. In conclusion, dynamic MRI with MRCP is an accurate and a reliable method of showing gall bladder carcinoma and in assessing its local and regional extent as part of preoperative assessment.

Diagnostic imaging of carcinomas of the gallbladder and the bile ducts

Early diagnosis and accurate staging of carcinomas of the gallbladder and the bile ducts are helpful in improving the prognosis. Ultrasonography (US), a useful initial modality when exploring the background of jaundice or non-specific gastrointestinal complaints, sensitively reveals bile duct obstruction in particular. In unclear cases, or if US suggests a resectable biliary malignancy, computed tomography (CT), magnetic resonance imaging (MRI) with magnetic resonance cholangiography (MRC) and / or traditional cholangiography often provide additional information, and imaging-guided fine-needle biopsy or an endoscopic brush sample may verify the malignant nature of the tumor. Complementary modalities are usually needed for accurate staging, and traditional cholangiography is often performed for therapeutic purposes as well. Comparative studies of MRI with MRC and multidetector CT in biliary cancers would be welcome.

Preoperative evaluation of gallbladder carcinoma: efficacy of combined use of MR imaging, MR cholangiography, and contrast-enhanced dual-phase three-dimensional MR angiography

PURPOSE

To determine the efficacy of the combined use of magnetic resonance (MR) imaging, MR cholangiography (MRC), and MR angiography (MRA) in the preoperative evaluation of gallbladder carcinoma.

MATERIALS AND METHODS

During a 20-month period, 41 patients with proven gallbladder carcinomas were referred for MR examination, including MR imaging, MRC, and gadolinium-enhanced dual-phase MRA to determine the operability of their gallbladder carcinoma. Eighteen patients who underwent surgery within six days of the MR examination were included in this study. All MR images were analyzed in order to assess bile duct invasion, vascular invasion, hepatic invasion or metastasis, lymph node metastasis, and invasion into adjacent organs.

RESULTS

Surgical and histopathologic findings revealed hepatic invasion in nine patients, bile duct invasion in nine, vascular invasion in three, and lymph node metastasis in 10. The sensitivity and specificity of MR examination were, respectively, 100% and 89% for bile duct invasion, 100% and 87% for vascular invasion, 67% and 89% for hepatic invasion, and 56% and 89% for lymph node metastasis.

CONCLUSION

The "all-in-one" MR protocol, including MR imaging, MRC, and MRA, can be an effective diagnostic method in the preoperative work-up for gallbladder carcinoma.

Diagnosis and staging of gallbladder carcinoma. Evaluation with dynamic MR imaging

The purpose of this study is to determine the ability of dynamic magnetic resonance imaging (MRI) in the diagnosis and staging of gallbladder cancer (GBC). Images of dynamic MRI of hepatobiliary system combined with MR cholangiography (MRC) of 18 patients with pathologically proved gallbladder cancer were correlated with pathological and operative findings. Focal or diffuse wall thickening was present in 10 patients. In five patients, the tumor appeared as a fungating or intramural mass. A tumor replacing the gallbladder was found in two patients and a small cancer in cystic duct in one patient. The tumor featured early and irregular enhancement, which persisted throughout the dynamic study. Metastatic nodes were found by surgicopathology in 13 patients and were depicted by the dynamic MRI in 11 patients. Local invasion to liver was found by surgery in 12 patients and correctly detected by MRI in 11 patients. MRI detected duodenum invasion in three out of six patients and none of the three cases with omental metastasis. In conclusion, dynamic MRI is useful and reliable in staging of advanced gallbladder cancer. MRI combined with MRC is sensitive in detection of obstructive jaundice, liver invasion as well as liver and lymph nodes metastasis. It is more difficult to delineate the invasion to duodenum and omental metastasis by MRI.

Gallbladder carcinoma: findings at MR imaging with MR cholangiopancreatography

PURPOSE

To describe magnetic resonance (MR) imaging and MR cholangiopancreatography (MRCP) findings in gallbladder carcinoma, and to correlate these findings with available surgical and biopsy information.

METHODS

Preoperative MR images (T1-weighted spin-echo, T2-weighted fast spin-echo, single shot fast spin-echo, and dynamic gadolinium-enhanced gradient echo) in 34 patients with gallbladder carcinoma were retrospectively reviewed for appearance of the primary neoplasm and for demonstration of hepatic, peritoneal, duodenal, and nodal involvement. Imaging findings were then compared with surgical findings (n = 19 patients) and histologic findings (n = 15 patients).

RESULTS

Gallbladder carcinoma manifested at MR imaging as focal gallbladder wall thickening with an eccentric mass in 76% (26/34) of cases. The most common types of regional spread demonstrated were direct liver invasion in 91% (31/34), lymphadenopathy in 76% (26/34), and biliary tract invasion in 62% (21/34). Sensitivity for direct hepatic invasion was 100%, and was 92% for lymph node metastasis.

CONCLUSION

MRI and MRCP can provide information relevant to preoperative staging of gallbladder carcinoma.

MR imaging of the gallbladder

T2-weighted imaging and MRCP, which have high sensitivity to edema and fluid, are paramount in the evaluation of certain gallbladder diseases, such as cholelithiasis, cholecystitis, adenomyomatosis, and cystic duct abnormalities. Dynamic gadolinium-enhanced MR imaging has the potential to differentiate among the many nonspecific-appearing lesions involving the gallbladder. MR imaging may not yet replace ultrasound as the workhorse of acute gallbladder imaging. Currently, MRCP is an ideal complementary study to inconclusive sonographic studies and can help plan surgical intervention in the setting of acute cholecystitis. Further investigation of hepatobiliary contrast agents, however, may reveal that MR imaging may be considered as first-line imaging in the acute setting.

Current perspectives in gallbladder carcinoma

Carcinoma gallbladder (CaGB) is not a common malignancy in a large number of countries in the world, except Chile, Japan, some parts of India, and a few other regions. Lacunae exist even today in terms of understanding of its epidemiology, aetiopathogenesis, and in the early pick up of malignanacy, as well as in choosing the most appropriate treatment option for a given case. While Japanese surgeons have advocated radical resections for CaGB and have shown good outcome resulting in long- term survival, others have not felt convinced about the desirability of undertaking such morbid surgical procedures in all patients. Also, radical resections have not always resulted in a tumor-free state and a cure in a large percentage of cases. Under the circumstances, the clinician's mind is often confused as to the most beneficial option for that patient once curative resection is not possible. Palliation of the jaundice and/or gastric outlet obstruction relieves the symptoms but does not prolong survival. The role of adjuvant chemotherapy with or without cytoreductive surgery has not been fully explored in CaGB. The present review quotes experience that seems to support the above contention. However, a number of well-designed multicentric trials are required to confirm the above philosophy of treatment for the benefit of patients suffering from CaGB.

Role of magnetic resonance imaging in the staging of gastrointestinal neoplasms

A concise review is presented of the current applications and techniques of magnetic resonance imaging (MRI) in the field of diagnostic imaging of oncologic disease of the gastrointestinal tract, with a summary of the diagnostic possibilities of MRI in the various types of tumor pathology of the gastrointestinal tract. We conclude with a review of the specific situations in which MRI presents distinct advantages over other diagnostic imaging methods (such as computed tomography and ultrasound).

Gallbladder carcinoma: radiologic-pathologic correlation

Primary carcinoma of the gallbladder is an uncommon, aggressive malignancy that affects women more frequently than men. Older age groups are most often affected, and coexisting gallstones are present in the vast majority of cases. The symptoms at presentation are vague and are most often related to adjacent organ invasion. Therefore, despite advances in cross-sectional imaging, early-stage tumors are not often encountered. Imaging studies may reveal a mass replacing the normal gallbladder, diffuse or focal thickening of the gallbladder wall, or a polypoid mass within the gallbladder lumen. Adjacent organ invasion, most commonly involving the liver, is typically present at diagnosis, as is biliary obstruction. Periportal and peripancreatic lymphadenopathy, hematogenous metastases, and peritoneal metastases may also be seen. The vast majority of gallbladder carcinomas are adenocarcinomas. Because most patients present with advanced disease, the prognosis is poor, with a reported 5-year survival rate of less than 5% in most large series. The radiologic differential diagnosis includes the more frequently encountered inflammatory conditions of the gallbladder, xanthogranulomatous cholecystitis, adenomyomatosis, other hepatobiliary malignancies, and metastatic disease.

Magnetic resonance imaging and diseases of the liver and biliary tract. Part 2. Magnetic resonance cholangiography and angiography and conclusions

Magnetic resonance cholangiography (MRC) relies on the strong T2 signal from stationary liquids, in this case bile, to generate images. No contrast agents are required, and the failure rate and risk of serious complications is lower than with endoscopic retrograde cholangiopancreatography (ERCP). Data from MRC can be summated to produce an image much like the cholangiogram obtained by using ERCP. In addition, MRC and conventional MRI can provide information about the biliary and other anatomy above and below a biliary obstruction. This provides information for therapeutic intervention that is probably most useful for hilar and intrahepatic biliary obstruction. Magnetic resonance cholangiography appears to be similar to ERCP with respect to sensitivity and specificity in detecting lesions causing biliary obstruction, and in the diagnosis of choledocholithiasis. It is also suited to the assessment of biliary anatomy (including the assessment of surgical bile-duct injuries) and intrahepatic biliary pathology. However, ERCP can be therapeutic as well as diagnostic, and MRC should be limited to situations where intervention is unlikely, where intrahepatic or hilar pathology is suspected, to delineate the biliary anatomy prior to other interventions, or after failed or inadequate ERCP. Magnetic resonance angiography (MRA) relies on the properties of flowing liquids to generate images. It is particularly suited to assessment of the hepatic vasculature and appears as good as conventional angiography. It has been shown to be useful in delineating vascular anatomy prior to liver transplantation or insertion of a transjugular intrahepatic portasystemic shunt. Magnetic resonance angiography may also be useful in predicting subsequent variceal haemorrhage in patients with oesophageal varices.

Biliary obstruction: findings at MR cholangiography and cross-sectional MR imaging

Twenty-two patients with malignant biliary obstruction and 21 patients with suspected obstruction of biliary-enteric anastomoses were evaluated over a 12-month period with magnetic resonance (MR) cholangiography and cross-sectional MR imaging. In patients with malignant obstruction, MR cholangiography helped accurately determine the status of the biliary ductal system by identifying the exact location and extent of the obstruction and the severity of duct dilatation. In so doing, MR cholangiography helped determine whether percutaneous transhepatic cholangiography with antegrade stent placement or retrograde cholangiography with stent placement constituted the more suitable treatment. Cross-sectional MR imaging was necessary to identify the organ of tumor origin, define the tumor margins, and determine the stage of disease. This information helped evaluate the appropriateness of curative surgical therapy versus palliative drainage procedures. In patients with biliary-enteric anastomoses, MR cholangiography clearly depicted the site of the anastomosis and demonstrated the status of the intrahepatic ducts, thereby helping determine which patients would benefit from undergoing antegrade duct cannulation with a drainage procedure or perhaps balloon dilation. In some of these patients, MR cholangiography was sufficient to help plan therapeutic intervention. MR cholangiography also demonstrates the presence and size of biliary stones and associated findings such as intraductal tumor growth. In addition, MR cholangiography may obviate retrograde cholangiography, which can be technically difficult to perform.

MRI findings in adenosquamous carcinoma of the gallbladder

In this report, we present the MRI findings of adenosquamous carcinoma of the gallbladder, a rare type of gallbladder malignancy. MRI examination not only helped established the diagnosis but also accurately depicted the extent of involvement of the adjacent liver. The ability to image in multiple planes was also useful in assessing the anatomic location of the tumor and in determining that the patient could be treated with surgical resection.

Dynamic MRI using a surface coil in chronic cholecystitis and gallbladder carcinoma: radiologic and histopathologic correlation

PURPOSE

The purpose of this study was to determine whether dynamic MRI could differentiate gallbladder carcinoma from chronic cholecystitis.

METHOD

The dynamic MR findings of 50 patients with pathologically proven chronic cholecystitis and 13 with gallbladder carcinomas were correlated with the pathological findings.

RESULTS

In chronic cholecystitis with thickened wall, mucosa and muscle were shown in early images as smoothly delineated enhancement except in one case, and the subserosa with fibrosis was enhanced in late or delayed images. Unenhanced foci in the wall correlated with Rokitansky-Aschoff sinuses or mural stones. In carcinomas, all tumors showed irregularly delineated enhancement in early images. In late or delayed images, noncancerous portions were also enhanced. The outer margin of early enhancement correlated with the extension of the tumor.

CONCLUSION

Dynamic MRI is useful for the differentiation of chronic cholecystitis from carcinoma and for the evaluation of its local extension.

Dynamic MRI of the gallbladder lesions: differentiation of benign from malignant

Forty-nine pathologically proven gallbladder lesions were evaluated in 45 patients using dynamic MRI with a spoiled gradient pulse sequence (SPGR), to access the ability of this technique to differentiate benign from malignant gallbladder lesions. The studies were reviewed retrospectively. Signal intensity of the lesions were measured. Twenty-one malignant and 28 benign lesions were classified into three categories: polypoid, diffuse wall thickening, and exophytic. Early and delayed enhancement patterns were evaluated. For the polypoid masses, malignant lesions (n = 9) demonstrated early and prolonged enhancements, whereas benign lesions (n = 14) had early enhancement with subsequent washout (P < .05). For diffuse gallbladder wall thickening, malignant lesions (n = 6) demonstrated early and prolonged enhancement and benign lesions (n = 14) showed relatively slow, prolonged enhancement (P < .05). The exophytic masses (n = 6) all were malignant and demonstrated early and prolonged enhancement. Dynamic MRI can help differentiate benign from malignant gallbladder lesions.

Radiological findings in cases of gallbladder carcinoma

Radiological findings in 80 cases of gallbladder carcinoma are analysed retrospectively. Seventy-nine of the patients had been examined by US (ultrasonography), 37 by CT (computed tomography), 26 by PTC (percutaneous transhepatic cholangiography), 17 by ERCP (endoscopic retrograde cholangio-pancreaticography), nine by angiography and 27 by US-guided FNB (fine needle biopsy). US showed the primary tumour in 68% and CT in 57%. In 67 cases the tumour had spread outside the gallbladder area, causing bile duct obstruction in 41. US showed the bile duct obstruction in 39 of these cases and CT in 20 out of 22 cases. US showed 73% of the cases that had spread to the liver; the sensitivity being 68% for direct invasion and 88% for peripheral liver metastases. The corresponding percentages for CT were 68, 67 and 75%, respectively. In lymph node enlargement, US showed the nodes in 70% of cases and CT in 52%. PTC showed either stenosis or total obstruction in 25 cases and failed in one case. ERCP showed a tumour in 76% and failed in 24%. Angiography failed to show the primary tumour in two instances out of nine. The results indicate that current imaging methods are insufficient for the accurate staging of gallbladder carcinoma.

Hepatocellular carcinoma invading the gallbladder: CT, arteriography and MRI findings

Hepatocellular carcinoma (HCC) seldom invades the gallbladder. We report a case of HCC invading the gallbladder that resembled gallbladder carcinoma invading the liver. The diagnosis was confirmed by surgical biopsy. The arteriographic, computed tomography and magnetic resonance imaging findings are presented.

Bile duct disease: prospective comparison of ERCP, CT, and fat suppression MRI

The authors compared computed tomography (CT) and endoscopic retrograde cholangiopancreatography (ERCP), techniques commonly used to study the biliary tree, with pre- and post-Gd-DTPA breath-hold fast low angle shot (FLASH) and fat suppressed spin-echo in 28 consecutive patients with bile duct abnormalities detected on ERCP, including 11 patients with malignant disease and 17 patients with benign disease. ERCP, CT, and magnetic resonance (MR) images were prospectively interpreted in a blinded fashion and reviewed by consensus. ERCP characterized all cases of malignant disease by the presence of a narrowed bile duct lumen with irregular margins. CT and MRI detected all cases of malignant disease and characterized nine of 11 as malignant. In seven of these cases, CT and MRI showed thickening of extrahepatic bile duct walls greater than 5 mm. MRI images showed intrahepatic-enhancing periportal tissue in four cases, which was not seen on CT images, and which was biopsy-proven tumor extension. Benign disease was characterized on ERCP images by the demonstration of smooth tapered narrowings in 16 cases, whereas on CT and MR images it was characterized by mild to moderate dilatation of the intrahepatic bile ducts and wall thickness less than 5 mm in 13 cases. Overall ERCP correctly characterized 27 cases as benign or malignant and CT and MRI both characterized 25. The results of this study show a trend that ERCP is superior to CT and MRI for characterizing bile duct disease.